Download LMC model, Hepatitis B - League of Minnesota Cities

Hepatitis B Vaccination Declination Form
I understand that due to my occupational exposure to blood or other potentially
infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection.
I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no
charge to myself. However, I decline Hepatitis vaccination at this time. I understand
that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a
serious disease. If in the future I continue to have occupational exposure to blood or
other potentially infectious materials and I want to be vaccinated with Hepatitis B
vaccine, I can receive the vaccination series at no charge to me.
I have read this form and understand its contents. Employee’s initials: ______________
Employee Printed Name
Employee Signature
Date
Witness Printed Name
Witness Signature
Date
League of Minnesota Cities
Potential Infectious Disease Exposures in Municipal Operations
4/4/2016